A PLEA FOR EARLY DIAGNOSIS IN 
THE PELVIC DISEASES OF 
WOMEN. 
BY 
B. F. BAER, M. D, 
PROFESSOR OF GYNECOLOGY IN THE PHILADELPHIA POLYCLINIC AND COLLEGE FOR 
GRADUATES IN MEDICINE. 
REPRINTED FROM 
THE PHILADELPHIA POLYCLINIC JOURNAL, 
MARCH, 1892. A PLEA FOR EARLY DIAGNOSIS IN THE PELVIC 
DISEASES OF WOMEN.1 
By B. F. Baer, M. I). 
PROFESSOR OF GYNAECOLOGY IN THE PHILADELPHIA POLYCLINIC. 
Gentlemen:-Skill in diagnosis is the highest accomplish- 
ment to which the. physician can attain, and the degree to 
which this faculty is possessed and developed will forecast 
the future measure of his success or failure. But failure of 
a medical career from a lack of diagnostic skill is so far 
reaching and disastrous in its consequences that no one' 
who aspires to enter and practice the profession of medicine 
should fail to cultivate and apply to the uttermost extent 
the power to recognize and differentiate disease. That 
"Knowledge is Power" is nowhere more easily demon- 
strated than in the advantage which the thorough diag- 
nostician possesses over the physician who is less skilful 
and painstaking in his efforts to learn the true condition of 
his patient. 
If the question were-submitted to me, I would urge the 
medical student whom I found to be lacking in the qualifi- 
cations necessary for the development of diagnostic skill, to 
relinquish at once the study of medicine and take up some 
other vocation or profession in which he might attain 
greater power for usefulness; and I believe that would be 
wise and humane legislation which would prevent the 
advancement of those students who were found wanting in 
this faculty. It is not, however, to medical students, or at 
least not to undergraduates, that I am now speaking but 
to those who have, by contact with disease, already learned 
to appreciate the value and necessity of further practical 
JAn Evening Lecture at the Polyclinic. 
1 2 
BAER, 
knowledge. This is evidenced by your presence at the 
Polyclinic, where opportunity is afforded to the physician 
to supplement what has been done at the undergraduate 
school and to strengthen the places which he has 'found 
weak. 
It is my purpose in this lecture, and in several others 
which are to follow, to call your attention to some of the 
traditional sophistries which have been handed down to us 
from a former generation and which have led to some 
serious errors in diagnosis. One of the most important of 
these is the so-called menopausal haemorrhage. 
By a strange reasoning, which may partly be explained 
by the fact that it occurred in the days when phlebotomy 
was regarded as almost a panacea, the idea that metror- 
rhagia at the change of life is physiological, gained a foot- 
hold in the profession, and through it was engrafted on the 
popular mind; and it has extended its evils to the present 
time, for many physicians still believe that the haemorrhage 
is beneficial at this period, that the blood loss is depuratory 
and that it protects the vital organs from injurious or even 
fatal congestion. This is one of the most dangerous fal- 
lacies that was ever advanced in medicine, for there is not 
the slightest ground, either in reason or in statistics for 
such an erroneous belief. If it were true, more cases of 
metrorrhagia ought to be met with, at this period of life, or 
more women should suffer from serious cerebral and other 
internal congestions, when the bleeding does not occur. 
Statistics show that the mortality during the five years from 
forty-five to fifty is no greater than the ordinary increase 
for each five years of advancing age, and that it is not any 
higher in females than in males for the same period of life. 
A careful analysis of thousands of cases of which I have 
notes, shows that the percentage of cases of metrorrhagia is 
less in those from forty to fifty than in those from thirty to 
forty years of age. Further, in those cases in which the 
cessation is gradual and without more than the ordinary 
flow, better health is enjoyed than when the so-called 
critical floodings occur. In health, the decline and cessa- EARLY DIAGNOSIS OF PELVIC DISEASE. 
3 
tion of the menstrual function takes place without turbu- 
lent activity. It should therefore be an axiom in gynaecol- 
ogy that metrorrhagia at the menopausal age, as at other 
periods of life, is never physiological, but always the result 
of local disease. The acceptance of this principle would 
save much suffering and prolong life, for we would then 
endeavor to discover the source of the haemorrhage before 
the disease had become incurable, instead of excusing our 
lack of care or want of knowledge, and quieting the 
patient's anxiety, with the statement that, "It is the change 
of life. " 
To illustrate and emphasize the danger which comes 
from delay in diagnosis as a result of the prevalent belief 
that metrorrhagia about the menopause is physiological, 
permit me to cite a few marked instances of many that 
have come to my notice. 
Mrs. X. was forty-seven years of age, married and had 
three children, the youngest of whom was twenty-two years 
old. She had a miscarriage two years after the birth of the 
last child, but since then she had not been pregnant. In the 
interval between the occurrence of the miscarriage and the 
beginning of the present trouble, she suffered occasionally 
from leucorrhoea and slight metrorrhagia, with pain in the 
sacrum. But to this she gave little attention and considered 
herself well. About three years before she consulted me she 
began to lose more than the usual amount of blood at her cat- 
amenial periods, and the quantity gradually increased with 
each recurrence, until it amounted at times to a severe flood- 
ing. She then began to have a watery fetid discharge in the 
intervals. She now became anxious regarding her condi- 
tion, but her fears were quieted by the "wise women" of 
her circle, who said it was " change of life," and advised 
her to let " nature take its course. " And nature did take 
its course, for the metrorrhagia and the fetid discharge con- 
tinued, and she became cachetic. Being now alarmed she 
consulted a physician, but one who was unfortunately 
biased in favor of the theory that metrorrhagia at the age 
of the menopause is physiological. He made an examina- 4 
BAER, 
tion, and found that the cervix uteri was hypertrophied 
and lacerated, and that the body of the uterus was also 
somewhat enlarged, but failed to discover the real cause of 
the haemorrhage. He informed her that this was not 
enough to produce the haemorrhage, that it must be the 
result of the approaching cessation, and advised her not to 
worry about it. This was nearly a year previous to the 
date at which she first consulted me. When I saw her she 
impressed me as one in the last stage of malignant disease, 
and I imagined that I could detect the peculiar odor of 
cancer, so great were the anaemia and cachexia. She had 
lost all desire for food, was emaciated, and had become so 
weak that she could scarcely sit up without fainting and 
was in such constant dread of sudden death that she had 
become painfully hysterical. I found the cervix uteri con- 
siderably hypertrophied, soft and lacerated. The os was 
patulous and dilatable, and the mucous membrane of the 
cervical canal congested and abraded. The body of the 
uterus, as outlined by conjoined manipulation, was found 
as large as at the third month of gestation, symmetrical, 
smooth, and rather soft. I next attempted to pass the 
finger into the uterine cavity, but it was arrested at the 
internal os by a rounded soft tumor. This manipulation so 
increased the haemorrhage that it was necessary to tampon 
the vagina to control it. I made a diagnosis of degenerat- 
ing sub-mucous fibroid tumor, but feared .it might possibly 
prove to be a malignant growth from the mucous mem- 
brane. The patient entered my private hospital and 
after the necessary preparation the tumor was removed. 
It proved to be a fibroid as large as a duck's egg, and it 
was a benign growth. Exploration of the uterine cavity 
with the finger after the operation was completed, showed 
the organ to be free from disease. Her recovery was un- 
interrupted, and there has not been any haemorrhage since 
the removal of the tumor; she has not even menstruated, 
the menopause having been established. 
On January 23, 1892, Mrs. A. was brought to my office 
by her physician and her husband. She was so reduced in EARLY DIAGNOSIS OF PELVIC DISEASE. 
5 
strength, from loss of blood and extreme suffering that she 
was almost constantly confined to bed. Her cachetic and 
anaemic appearance resembled that seen in the advanced 
stage of carcinoma of the uterus. The history obtained was 
as follows: She was forty-six years of age and had two chil- 
dren, the youngest being fourteen years. Ten years ago she 
began to suffer from menorrhagia. The flow was at first 
only slightly above the normal, but it gradually increased 
in quantity and on several occasions during the last two 
years, she has had such profuse Hooding that she was in 
extreme collapse from loss of blood. Finally, she began 
to have a fetid discharge in the intervals between the 
bleedings and showed evidence of septic poisoning. During 
these years of bleeding she has had very little medical 
attention because it was thought that she was passing 
through the " change of life. " This belief was encouraged 
by several physicians who were consulted. During the 
last year she has suffered with attacks of uterine tenesmus 
which have been increasing in severity and during the last 
month she has had severe bearing down pains, "just 
like those of childbirth. " These pains had somewhat 
diminished during the previous week, but she then began 
to suffer with inability to void her urine. Her present 
physician made an investigation when first called to see 
her and found a mass occupying the vagina, which 
gave him the impression that his patient was suffer- 
ing from malignant disease of the neck of the womb, 
and that her malady was therefore probably incurable. 
In this I was disposed to agree with him, from the appear- 
ance of the patient and the odor that was quite per- 
ceptible even at a distance. But the history of the long 
continued haemorrhage and the peculiar character of the 
pains caused me to hope and believe that I would find a 
degenerating fibroid which the uterus was endeavoring to 
expel, and the result happily proved that I was correct. 
On examination I found, just within the vulvar orifice, 
a mass of pale, whitish tissue which resembled the 
appearance presented by carcinoma of the neck of the 6 
BAER, 
uterus. A finger was introduced within the vagina 
where a large, rounded mass was found, entirely filling 
the pelvis and pressing firmly upon the urethra and 
rectum. The tumor was as large as a child's head and 
occupied the position which that organ occupies in the 
second stage of labor. By carrying the fingers up and 
around this mass I was just able to feel the rim of the 
cervix which was greatly dilated. At several points the 
surface of the tumor was friable but there was a tough- 
ness at its upper portion which caused me to believe 
that the growth was fibrous. Placing my hand upon 
the hypogastrium I found there a circumscribed tumor 
which, from its fluctuating character and shape, I believed 
to be the distended bladder. A catheter was at once intro- 
duced and at least three pints of urine flowed, the hypogas- 
tric tumor disappearing and the patient immediately feeling 
greatly relieved. Operation was advised and, with the 
assistance of Dr. W. A. N. Dorland and Dr. Bechtel it was 
performed at her home on the next day. 
After the patient was anaesthetized and on the table, 
her family physician urged me not to proceed with the 
operation should it prove, on further examination, to be 
malignant and I must confess that the markedly cachetic 
appearance of the patient and the odor, caused me, even then, 
to doubt the correctness of the opinion which I had expressed 
the day before. After thorough irrigation with bichloride 
solution I convinced myself that the tumor was a fibroid, but 
I was not sanguine as to the result of an operation at this late 
stage, for the discharge had a decided faecal odor and I feared 
that the pressure had caused a perforation of the rectum at 
the upper portion of the vagina. I proceeded, however, to 
break down the softened degenerated portion of the tumor. 
The remainder proved to be exceedingly tough and required 
the greatest effort to deliver it through the vulvar orifice. 
When the tumor was removed'from the vagina it was found 
to be attached to the fundus of the uterus by a good sized 
pedicle. This was severed with scissors. The uterus was 7 
EARLY DIAGNOSIS OF PELVIC DISEASE. 
now found to be almost entirely inverted, but I succeeded 
in replacing it. There was very little haemorrhage, and 
after thoroughly irrigating and tamponing the cavity of 
the uterus and vagina the operation was concluded and 
the patient returned to bed. She made a good recovery. 
Permit me to refer to another danger to which women suf- 
fering from metrorrhagia at this period of life are exposed, 
by the fallacy of regarding the haemorrhage as physiologi- 
cal. Cancer of the uterus is regarded by many physicians 
as necessarily fatal from its incipiency, and they therefore 
look upon operative interference as futile, and as unwar- 
rantably subjecting the patient to the pain and danger of a 
useless effort to eradicate or even to palliate the disease. Now 
suppose that these patients had consulted some one who held 
such views, and that he had concluded from the history, symp- 
toms, and the general appearance of the patients that they 
were cases of cancer-which they resembled very closely- 
and then on examination the disease had been pronounced 
malignant and non-interference advised. The patients would 
certainly have succumbed to the haemorrhage caused by a 
benign tumor. That is exactly what did occur in the 
following case. 
Not long ago I was called to a neighboring county to see 
a patient who was said to have cancer of the womb. I 
found her in a dying condition and presenting the appear- 
ance of one in the last stage of carcinoma. The history I 
obtained was as follows : 
Two or three years previously she began to lose more 
than the normal amount at her menstrual periods. This 
had increased until the blood-loss amounted at times to a 
flooding, and there had also been a watery, fetid dis- 
charge. She had in the meantime been under the care of 
her physician who at first ascribed the haemorrhage to the 
change of life, although later he had prescribed remedies 
for the purpose of controlling the bleeding. But an intelli- 
gent examination had not been made, nor had counsel been 
asked until this late stage of the disease had been reached. 8 
BAER, 
On examination I found the vagina filled with a degenerat- 
ing fibrous polypus which was attached by a small pedicle 
within the uterine cavity. It was so easily removable and 
so tempting that I at once, while making the examination, 
broke the pedicle with my fingers and removed the tumor, 
which was about the size of the fist. The operation did not 
require three minutes' time, nor the removal of the patient 
from her bed. The removal of the tumor, however, did not 
have the slightest effect upon her and she died a few days 
afterwards, another sacrifice to traditional error! 
Why should there be a necessity for haemorrhage at the 
menopause? It has no analogy in comparative physiology, 
and it does not relieve symptons. On the contrary those 
very women who suffer with irregular haemorrhages at this 
period, are the ones who are most troubled with the so- 
called nervous signs of the approaching change of life, as 
flushings, etc. Apoplexy is very uncommon in the female 
at this age; and when it does occur it probably results from 
anaemia and not from plethora. I believe that women 
suffer less about the menopause since venesection has been 
abandoned than when it was practiced regularly. Let me 
relate the following case in illustration, which, with others, 
long ago proved to me that it is to the pathological condi- 
tion which results in the haemorrhage, that is due the 
various nervous disturbances common to this period and 
which are usually ascribed to the age of the patient. 
Mrs. W. first consulted me in January, 1878. She was 
then forty-three years of age, and had six children, the 
youngest being twelve years. She had suffered from menor- 
rhagia since the birth of her last child, and recently from 
metrorrhagia, which would amount at times to enough to 
be designated a " flooding. " She also had occasional attacks 
of rectal haemorrhage during the last few years. In addi- 
tion to the loss of blood, she suffered intensely from the 
burnings and flushes, vertigo, palpitation, dyspepsia, and 
other nervous disturbances, to which women at this age 
are especially liable when the functions of the generative system EARLY DIAGNOSIS OF PELVIC DISEASE. 
9 
are not performed properly, i. e. when there is a diseased con- 
dition present. 
The uterus was found large, soft from engorgement, 
and sharply retroflexed, but it was mobile aiid not tender 
on pressure. The cervix was involved in the general con- 
gestion and hypertrophy of the uterus, but was not other- 
wise diseased. The sound indicated a soft, hypertrophied 
endometrium. Except in partaking of the general conges- 
tion, the pelvic tissues and organs around the uterus 
appeared to be normal. Examination of the rectum, how- 
ever, showed the haemorrhoidal vessels to be in a varicose 
condition. 
The plan of treatment followed in this case was one 
designed to restore tone to the uterine and pelvic vessels 
and tissues, to thereby reduce the amount of blood circulat- 
ing in that locality; and it consisted in the reposition of 
the uterus and the occasional use of the curette, with 
the application of the appropriate remedies to the uterine 
cavity, together with the general medication indicated. It 
is sufficient for my purpose to state that as the metror- 
rhagia diminished and the catamsenia became more regular, 
the nervous and other symptoms subsided; but when 
the haemorrhage would return, which occurred a number of 
times during the next two years, at the end of which time 
the menopause was established, the nervous symptoms 
would return. After the cessation of the catamaenia, the 
patient remained well, until she began again to lose blood 
from the rectum, when the nervous symptoms returned 
with such severity as to suggest to her physician that the 
haemorrhage was probably vicarious, or supplementary to 
the menstrual flow. The vertigo was especially marked, so 
that the patient was in dread of apoplexy, and thought that 
the haemorrhage was conservative. She was bled from the 
arm, on several occasions by her family physician. But this 
had no other effect than to quiet for a time her disordered 
mental condition, and she finally consented to submit to the 
removal of the haemorrhoids, and that operation was performed 
in 1883. She has not lost any blood since, and she informed 10 
BAER, 
me recently that she has continued in excellent health. I 
do not think it can be said that the metrorrhagia in this case 
was at any time physiological, or that the haemorrhage 
from the rectum was conservative, in protecting the patient 
from apoplexy or other serious disease. 
To further show the danger of neglecting patients who 
are suffering from metrorrhagia at the period of the meno- 
pause, let me relate the following cases of malignant dis- 
ease : 
The first case was sent to me by Dr. D. P. Pancoast of 
Camden, N. J. The patient was forty-two years of age and a 
widow. She had had five children, the last one six years 
ago. Pier labors had been unusually difficult. About two 
years before I first saw her, she found that she was losing 
more blood at the catamsenial epochs than usual, and that 
her strength was failing as a result. The irregular haemor- 
rhage was attributed to the " change of life, " and the 
patient was advised to submit to the loss until the meno- 
pause should have been reached. But the haemorrhage 
rapidly increased until she was rarely free from it, and she 
was extremely emaciated when Dr. Pancoast was consulted. 
The doctor found the os uteri widely dilated and a mass of 
tissue, polypoid in form, projecting from it; this he sus- 
pected to be malignant. My examination confirmed his 
suspicions, for the growth was of a very friable, vascular 
character, and on passing my finger within the uterine 
cavity I found that it originated from many points on the 
surface of the mucous membrane. The cervix was not 
involved in the disease, and the body of the uterus was 
mobile. Hysterectomy was considered, as the disease 
seemed to be confined to the uterus, but we concluded that 
the patient was now so exhausted that she would almost 
certainly succumb to so radical an operation. To check 
the haemorrhage for a time and rid the patient of the 
degenerating and decomposing tissue which was rendering 
her life a burden, and with the hope that she might regain 
strength, the diseased tissue was scraped away and the sur- 
face cauterized. EARLY DIAGNOSIS OF PELVIC DISEASE. 
11 
The improvement of the patient was so rapid that within 
a month she was able to visit a friend who lived at a 
distance. The haemorrhage and other discharges had 
ceased, and her color and weight had improved to a 
remarkable degree. But the respite was only temporary, 
as we had anticipated, for a few months afterwards she died 
from acute peritonitis, which, I think, resulted from haemor- 
rhage into the peritoneal cavity. Hysterectomy should 
have been performed as soon as she had recovered sufficient 
strength, but she wished to defer it. 
The second case was that of R. X., who consulted me in 
March, 1880. She was then aged forty-two years, married, 
had two children, the youngest ten years of age. Since the 
birth of the last child her menses had been rather profuse, 
and she had some leucorrhoeal discharge, with slight incon- 
venience in the pelvis and pain across the sacrum. Six 
months previous to the date at which I first saw her, she 
had an attack of metrorrhagia which lasted two weeks, and 
this had been repeated frequently within that time ;*she had 
not been able to go- out of the house, and rarely to leave 
her room, for three months. She had lost more than twenty 
pounds in weight, bad become pale, and suffered from great 
nervous prostration. 
Examination showed the uterus to be slightly retro- 
verted, considerably enlarged, and not freely movable. 
The cervix was somewhat hypertrophied, but was other- 
wise normal. The sound was passed through the internal 
os with difficulty, on account of some obstruction met with 
at that point, and indicated the uterine cavity to be large, 
soft, and rugous; and its withdrawal was followed by a very 
fetid, sero-purulent discharge. I diagnosticated fungous 
hypertrophy of the endometrium, but feared, from the 
degenerated condition of the tissues, that it might be malig- 
nant. I at once decided to dilate the cervical canal and 
remove the disease as far as possible. Tents were inserted 
and when they were removed, twenty-four hours later, the 
os was so patulous that the index finger could be readily 
introduced into the uterine cavity, which was found to be 12 
BAER, 
festooned with ridges of hypertrophied tissue. This was 
soft and ulcerating on the surface, but it was firm at its 
attachment to the uterine wall. I removed, by means 
of the polypus forceps and the sharpe curette, all the 
redundant growth, aggregating enough to fill the palm 
of my hand, and then thoroughly cauterized the surface 
with nitric acid. 
As soon as the patient had recovered from the immediate 
effects of the operation, I placed her upon the enforced 
discipline and diet of the " rest treatment, " together with 
tonic and alterative medicines appropriate to her condition. 
Antiseptic douches and an occasional application of equal 
parts of Churchill's solution of iodine and pure carbolic 
acid to the uterine cavity, completed the local treatment. 
Three months after the operation, she had gained fifteen 
pounds in weight, and was otherwise so much improved 
that she felt her health had been entirely restored. There 
had been no return of the metrorrhagia, and the cavity 
of the uterus appeared to be free from disease. She then 
went to spend the summer in the mountains of Penn- 
sylvania, and when she returned in the fall she looked the 
picture of health, and assured me that she was as well as 
she had ever been. Careful examination was made at this 
time, and I failed to detect any signs of a return of the 
malady. 
Twelve years have now elapsed since the operation, and 
this lady enjoys good health; there has not been the 
slightest evidence of a return of the disease, and examina- 
tion of the uterus confirms the outward appearances, for it 
seems to be in normal condition. 
The microscope showed these two cases to be of like 
malignancy (" endothelial cancer ",) differing only in the 
stage of the disease. 
These cases present the two extremes of the disease, and 
very forcibly illustrate and strengthen the position which I 
have taken as to the cause and treatment of metrorrhagia 
at this period of life ; and they show the value of seeking 
for and removing the cause of haemorrhage without delay. EARLY DIAGNOSIS OF PELVIC DISEASE. 
13 
For if the same decisive plan of treatment had been followed 
in the first case as in the second, when the first signs of the 
pathological change were manifested, the life of the patient 
very probably would have been prolonged, and possibly 
saved, i. e., the disease eradicated ; for there is a possibility 
that this form of disease in this locality (uterine cavity) is not 
essentially malignant in its incipiency, but only becomes so 
after the health has been undermined by a prolonged drain 
upon the system, thus destroying the inherent resisting 
power, or plastic force of the tissues, and allowing an 
activity of a lower type to take its place. 
But how shall we discover the disease in its incipiency? 
This can never be hoped for until we, as physicians, come 
to regard all irregular discharges from the uterus as the 
result of local disease, requiring immediate intelligent 
investigation, and teach women to so regard them. In this 
matter the physician must be the educator. It is true 
that in many cases the disease is so far advanced before the 
stage of ulceration is reached, upon which the discharges of 
cancer usually depend, that little, except to palliate the 
symptoms, can be hoped for; but there are also many 
exceptions; some in which the disease begins as a super- 
ficial ulcer; others in which the growth partakes of the 
nature of a papilloma in its early stages, and in these 
cases very much towards prolonging life and alleviating 
suffering may be accomplished. Then, by healing all 
sources from which these discharges originate, of whatever 
pathological character, it is possible that the soil, fertile for 
the development of the malignant affection, may be de- 
stroyed, and its growth prevented. 
2010 Chestnut Street.